PUBLIC HEALTH DIVISION

Oregon Medical Marijuana Program

Oregon Medical Marijuana Program Application Instructions

Before you start:
Type or print legibly. Do not change the form or use “White Out.” Put check or money order in the envelope with this
application. Do not staple or tape your check or money order to your paperwork. Keep copies of everything you submit to
the OMMP. Sections 1 and 4 are required.
If you see this symbol, additional documentation is required.
If you see this symbol, payment is required.

Section 1: Patient information

All applicants must complete Section 1: Patient information.
• Complete all the requested fields and provide the required documentation.
Required additional documentation for Section 1:
Proof of current Oregon residency for yourself. An Oregon-issued driver’s license or identification card is acceptable
residency proof. Other acceptable forms of residency proof include a recent utility bill or rental agreement.
Government-issued photo ID. Examples: Driver’s License, State ID, Military ID (must show date of birth), US Passport,
US- issued Visa, Permanent Resident Card, Tribal ID (including full name, date of birth and a photo). If you are
renewing and your government-issued photo ID from last year did not expire, a photocopy of your government-issued
photo ID is not required.
Attending Provider’s Statement (APS) or medical chart notes that contain a diagnosis of your qualifying condition and
a statement that medical marijuana may mitigate the symptoms or effects of your condition. Your medical
documentation must be signed and dated no more than 90 days from the day the OMMP receives it and cannot be
dated earlier than 90 days before your registration expiration date. Contact the OMMP for a form, or print the form
online at healthoregon.org/ommpforms.
 If you are a US veteran and can submit proof that you meet either of the qualifications below, you do not
need to submit medical documentation when renewing:
 Has been assigned a total and permanent disability rating for compensation that rates the veteran
as unable to secure or follow a substantially gainful occupation as a result of service-connected
disabilities described in 38 C.F.R.4.16; or
 Has a United States Department of Veteran’s Affairs total disability rating of 100% as a result of an
injury or illness that the veteran incurred, or that was aggravated, during active military service and
who received a discharge or release under other than dishonorable condition.

Section 2: Caregiver information

• Only patients who are designating a caregiver or who are under 18 years of age are required to fill out Section 2:
Caregiver information. If not, skip to Section 3.
• A caregiver must be 18 years of age or older.
• The patient’s provider cannot be a patient’s primary caregiver.
• A caregiver is a person with significant responsibility for managing the well-being of the patient.
• A patient under 18 years of age must name the patient’s custodial parent or legal guardian as their caregiver.
Required additional documentation for Section 2:
Government-issued photo ID. Examples: Driver’s License, State ID, Military ID (must show date of birth), US Passport,
US- issued Visa, Permanent Resident Card, Tribal ID (including full name, date of birth and a photo). If you are
renewing with the same registered Caregiver as last year and the government-issued photo ID you submitted for the
caregiver has not expired, a photocopy of the Caregiver’s government-issued photo ID is not required.
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Section 2: Caregiver information
The following additional documentation may be required based on your situation:
Patient is a minor: Patients under the age of 18 must submit a notarized Declaration of Person Responsible for a
Minor form signed by the minor’s custodial parent or legal guardian who is responsible for the minor’s health care
decisions. ORS 475C.783(3) Contact the OMMP for a form, or print the form online at healthoregon.org/ommpforms.
Patient is designating an organizational or facility caregiver. Complete the Organizational or Facility Caregiver
consent form and submit it with this application. Contact the OMMP for a form, or print the form online at
healthoregon.org/ommpforms.
 "Organization or facility caregiver" means: An organization that provides hospice, palliative or home
health care services that is licensed under ORS 443.014 to 443.105, 443.305 to 443.355, or 443.850 to
443.869 and has significant responsibility for managing the well-being of a patient OR a residential facility
as defined in ORS 443.400 that is licensed under ORS 443.400 to 443.455 and has significant
responsibility for managing the well-being of a patient.

Section 3: Grower and grow site information

• Only patients who are their own grower or designating a grower are required to fill out Section 3: Grower and grow site
information. If not, skip to Section 4.
• A grow site that is the patient’s residence, where the patient (or that patient’s caregiver) is the designated grower for
the patient, may not have more than 12 mature marijuana plants - if more than 2 patients are registered to the site.
• Visit healthoregon.org/ommpreporting to see if monthly inventory and transfer reporting requirements apply.
• A grower must be 21 years of age or older.
• Grow sites are subject to inspection.
Grower required additional documentation for Section 3:
Government-issued photo ID. Examples: Driver’s License, State ID, Military ID (must show date of birth), US
Passport, US- issued Visa, Permanent Resident Card, Tribal ID (including full name, date of birth and a photo). If you
are renewing with the same registered Grower as last year and the government-issued photo ID you submitted for the
grower has not expired, a photocopy of the Grower’s government-issued photo ID is not required.
Grow site required additional documentation for Section 3:
You must provide a United States Postal Service physical address for your grow site. If the site has no physical
address, you must provide the documentation outlined in OAR 333-008-0020(4)(b).
Proof of zoning is required if the grow site address is located within city limits. Zoning documentation can be obtained
from the county or city.
Grow Site Consent form: An application must include a Grow Site Consent form if the patient or the grower is NOT the
owner of the grow site property. Print the form online at healthoregon.org/ommpforms or contact the OMMP for a form.

Section 4: Patient signature and fees

Patient signature
The applicant, patient, must sign and date the application form.

Fees
Payment is required with this patient application. OMMP fees are non-refundable. Make checks payable to
OHA/OMMP. Do not send cash.

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 Print Save as Reset
PUBLIC HEALTH DIVISION
Oregon Medical Marijuana Program

Oregon Medical Marijuana Program Application (to be completed by patient)

*Sections 1 and 4 are required for all applicants. Be sure to sign section 4.
Section 1: Patient information (Section 1 is required.)
Name (first, middle initial, last): Date of birth: / /
Mailing address: Gender: M F X
City: State: ZIP: County:
Phone number:
Proof of Oregon residency (check one and enclose a copy): Oregon ID OR Other ID and residency proof
Government-issued photo ID number (enclose a copy if ID is new):
Attending Provider’s Statement (APS)
Section 2: Primary Caregiver information (Complete section 2 only if you have a caregiver. If not, skip to section 3.)
Name (first, middle initial, last): Date of birth: / /
Mailing address: Gender: M F X
City: State: ZIP: County:
Phone number:
Government-issued photo ID number (enclose a copy if ID is new):
Section 3: Grower and grow site information (Complete section 3 only if you are your own grower or designating a grower.
If not, skip to section 4. Reporting requirements may apply to growers.)
Name (first, middle initial, last): Date of birth: / /
Mailing address: Gender: M F X
City: State: ZIP: County:
Phone number:
Government-issued photo ID number (enclose a copy if ID is new):
Grow site information
Physical grow site address:
City: State: ZIP: County:
Grow site questions
1. Is the grow site inside city limits? Yes No
2. Is the grow site the patient’s residence? (Grow sites at a patient’s
residence may have lower plant limits. See instructions for details.) Yes No
3. Will the grower be transferring medical marijuana to a medical
marijuana dispensary or processing site? Yes No
4. Who is the owner of the property where the grow site is located? Patient Grower Other
(If “Other” is checked you are required to submit the Medical Marijuana Grow Site Consent form with this application.)
Section 4: Patient signature and fees (Section 4 is required.)
Patient signature
I attest the information provided is true and I understand my application may be denied or my cards suspended or revoked for
submitting false information. In addition, by signing I authorize OMMP to verify any information provided in this application
including but not limited to contacting the provider who signed the Attending Provider’s Statement or the property owner
providing consent for use of the grow site.
Patient signature: Date:

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Grow site required documentation
You may be required to provide the following documents and information to register your designated grower and grow site.
See instructions for details.
Proof of legal grow site address
Proof of grow site address zoning If you selected “Yes” for question 1 of the “Grow site questions”, you are required
to submit proof of grow site address zoning.
Grow site consent form If “other” is checked for question 4 of the “Grow site questions”, you are required to submit
the Medical Marijuana Grow Site Consent form with this application.

Application and grow site registration fee |

A patient application fee is required to be sent in with this application (see instructions for details).
Patient application fee: $200 unless patient sends proof of:
$60 Supplemental Nutrition Assistance Program (SNAP) benefits.
Discounted fees

$50 Oregon Health Plan (OHP) benefits.

$20 Supplemental Security Income (SSI). (Note: Social Security Disability Income and retirement benefits do not
f )
$20 Having served in the U.S. armed forces.
$0 A veteran who submits proof of having a U.S. Department of Veteran Affairs disability rating of at least 50% as
a result of injury or illness from active military service and received a discharge other than dishonorable.
Grow registration site fee (see instructions for details):
Growers will be mailed a letter with instructions on how to create an OMMOS account and pay their fee online.
$200 The grower must submit a $200 grow site registration fee if one or more of the following is true:
• The grow site is not the patient’s residence.
• The grower is not the patient on this form.
• The grower will be transferring medical marijuana to a dispensary or processing site.
$0 No grow site registration fee is required for patients growing for themselves at their own residence where
there are 12 or fewer mature medical marijuana plants.
OMMP fees are non-refundable. If you mail in these fees, make checks payable to OHA/OMMP. Do not send cash.
Growers may pay online after receiving notification from OMMP with payment instructions.
Growers must understand and comply with all grower requirements including reporting and tracking requirements.
For more information visit our webpage for Medical Marijuana Growers at: healthoregon.org/ommpgrower.
Mailing in your completed application
Mail your complete application, along with all required documentation (such as medical documentation, ID copies, residency
proof, consent forms as required, zoning documentation, proof of a legal address for the grow site and reduced fee proof as
applicable) and check/money order to:
OHA/OMMP You can get this document in other languages, large print, braille or a
P.O. Box 14450 format you prefer. Contact Oregon Medical Marijuana Program (OMMP)
Portland, OR 97293-0450 at 971-673-1234 or 711 for TTY.

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